Scope and Practice of Emergency Nursing - ANSWER -emergent, urgent, and critical care needs
-an emergency is whatever the pt or family considers it to be
-the emergency nurse has special training, education, experience
...
Scope and Practice of Emergency Nursing - ANSWER -emergent, urgent, and critical care needs
-an emergency is whatever the pt or family considers it to be
-the emergency nurse has special training, education, experience, and expertise in assessing and identifying health care problems in crisis situations
Emergency Nursing - ANSWER -pts with life threatening or potentially life-threatening problems enter the hospital through the ED
Triage - ANSWER -process of rapidly determining patient acuity
-represents a critical assessment skill
-triage process: pt who have a threat to life, vision, or limb are treated before another pts
-triage system: categorizes pt so most critical are treated first
-pt and family focused
Initial Assessment - ANSWER -a systematic process
-divided into 2 phases: primary and secondary
-must follow safety guidelines for protection of pt and staff
Pedi Assessment Triangle - ANSWER -appearance (#1)
-work of breathing
-circulation (color)
Emergency Airway Management - ANSWER -open the airway- keep it open
-airway is everything; without one nothing matters
-establishing and maintaining a patent airway
-ensuring effective oxygenation and ventilation
Head Tilt-Chin Lift Maneuver - ANSWER Indications:
-unresponsive
-NO spinal injury
-unable to protect airway
Contraindications:
-responsive
-possible spine injury
Advantages:
-no equipment
-Noninvasive
Disadvantages:
-hazardous to spinal injury
-no protection from aspiration
Jaw Thrust Manuever - ANSWER Indications:
-unresponsive
-possible spine injury
-unable to protect airway
Contraindications:
-resistance to opening mouth
Advantages:
-used with spine injury or cervical collar
-no special equipment required
Disadvantages:
-cannot maintain if pt becomes responsive or combative
-difficult to maintain for extended time
-difficult to use with bag mask ventilation
-thumb must remain in place
-requires second rescuer
-no protection against aspiration
Emergency Nursing - ANSWER Pt=primary survey focuses (ABCD)
-A: airway with cervical spine stabilization and/or immobilization
-B: breathing
-C: circulation
-D: disability (quick neuro check; AVPU)
-don't move on until the previous has been taken care of
-identifies LIFE THREATENING conditions
AVPU - ANSWER -A: ALERT
-V: RESPONSIVE TO VOICE
-P: RESPONSIVE TO PAIN
-U: UNRESPONSIVE
Secondary Survey - ANSWER -Definition: brief, systematic process to identify all injuries
-EFGHI
-E: exposure/environmental control
-F: full set of vitals/ five interventions/ facilitate family presence
-G: give comfort measures (pharm and nonpharm)
-H: history and head to toe assessment
-I: inspect entire body
-Evaluate need for tetanus prophylaxis
-provide ongoing monitoring (BP, O2, HR, primary survey)
-prepare to send
Death in ED - ANSWER -must recognize importance of hospital rituals in preparing the bereaved to grieve
-determine if pt could be candidate for non-heart beating donation
-call medical examiner (have SBAR and hx ready)
Gerontologic Considerations: Emergency Care - ANSWER Elderly @ high risk for injury:
-decreased visual acuity and peripheral vision
-hearing loss (esp high frequency sounds)
-pre existing disease and med use
-dementia and cognitive impairment
-main injury with elderly: falls
-are findings b/c fall or did they cause the fall
FYI: anyone who dies within 24hrs of arrival is a careeners case; leave in all tubes - ANSWER ...
After Death: - ANSWER -clean room
-clean pt
-remove unneeded equipment
-cover in warm blanket
-bring chairs/kleenex
-turn lights down
GI Emergency - ANSWER -Upper GI: esophagus, stomach, dudenum
-Lower GI: jejunum, ileum, colon, rectum
Peptic Ulcer Disease (PUD) - ANSWER -causes upper GI bleed
-causes: overuse of NSAIDs (#1), helicobacter pylori
Stress Related Erosive Syndrome (SRES) - ANSWER -can prevent
-causes upper GI bleed
-high risk for: post op, trauma, shock, burns, acute neuro disease, vent dependence
Medical Emergencies - ANSWER -Esophageal Varices: vessels in esophagus that become engorged
-@ risk for: eating d/o (V). alcoholics
-s/s: portal HTN
-Gastric Perforation
-s/s: sudden severe upper abd pain, radiates to R shoulder, rebound tenderness, rigidity
-sets you up for sepsis
Heat Exhaustion - ANSWER -prolonged exposure to heat
-occurs when body is unable to cool itself
-sxms may be vague
-general malaise, N, V, fatigue, light headed, diaphoresis, mild confusion, hypoTN
-temp of 99.6-104.0
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